腹腔镜技术在高位胆道外科中的应用研究
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摘要
第一章腹腔镜肝切除术在肝内胆管结石治疗中的应用
目的：探讨应用腹腔镜肝切除术治疗肝内胆管结石的可行性和治疗效果。
方法从2003年11月至2012年11月,对75例肝内胆管结石病人进行了手术的治疗。其中35例病人进行了腹腔镜肝切除术(laparoscopic hepatectomies, LH组),40例病人采用开腹肝切除术进行治疗(open hepatectomies,OH组)。两组病人的手术方式包括左肝外叶切除术、左半肝切除术、胆总管切开探查、胆道镜探查取石、T管引流、胆囊切除术。分析和对比两组病人的临床资料包括手术时间、术中出血量、术后止痛药使用情况、下床活动时间、恢复饮食时间、术后并发症、术后住院时间、结石清除率和复发率等因素。
结果：两组病人手术方式对比无显著差别。腹腔镜组的手术时间长于开腹组(205.0±40.9min VS155.0±26.6min, P<0.001)。腹腔镜组的术后住院时间比开腹组的短(12.3±2.6VS15.6±4.3,P<0.001)。腹腔镜组的术中出血量稍多于开腹手术组(330.0±259.7ml VS151.5±137.0ml,P=0.001),然而腹腔镜组后10例病人的出血量与开腹组的相当(81.0±19.7ml VS78.0±22.Oml,P=0.752)。腹腔镜组术后止痛药使用率低于开腹组(0%VS62.5%,P<0.001)。腹腔镜组比开腹组更早地恢复下床活动(1.5±0.5天VS3.6±0.7天,P<0.001)和进食时间(2.4±0.5天vs4.0±0.7天,P<0.001)。术后并发症发生率(2.9%VS16.0%)、结石清除率(即时清除率91.4%VS90%和最终清除率97.1%VS100%)在两组间均无明显差别,P>0.05。两组病人都没有围手术期死亡病人。73例(97.3%)病人获得随访,包括开腹组38例和腹腔镜组35,随访时间为5～113个月,平均41个月。腹腔镜组合开腹组的手术优良率无显著差别(97.1%VS100%,P=0.479)。每组分别有2例病人结石复发。
结论：选择合适的病例,腹腔镜肝切除术联合胆道镜治疗肝内胆管结石是安全可行的,可以达到与开腹手术同样良好的效果。腹腔镜肝切治疗肝内胆管结石具有伤口小、痛苦轻、恢复快、并发症少等微创手术的优势。
第二章腹腔镜带蒂胆囊瓣胆道修复术治疗合并主肝管狭窄的肝内胆管结石的应用研究
目的：探讨腹腔镜带蒂胆囊瓣胆道修复术治疗合并主管狭窄的左肝内胆管结石的安全性和可行性。
方法：2011年11月～2012年2月,对5例合并左主肝管狭窄的肝内胆管结石的患者施行腹腔镜带蒂胆囊瓣胆道修复术,5例均为女性,年龄25～60岁,平均47.4岁。手术方式为腹腔镜胆总管切开,胆道镜探查取石,胆囊部分切除,带蒂胆囊瓣胆道修复,T管引流术,其中有3例患者同时切除了肝左外叶。
结果：5例均成功完成腹腔镜带蒂胆囊瓣胆道修复术,无中转开腹,无死亡病例,平均手术时间274.6±25.4min(250-310min),平均术中出血量130.0±97.5m1(50-300m1)。5例病人均不需要进行左半肝切除术,其中2例病人不需要肝切除,其余3例病人只切除了肝左外叶,保留了肝左内叶的肝组织。1例病人出现并发症,该病人因脾损伤术后发生延迟性腹腔出血和肺炎,经过二次手术和抗生素治疗后治愈。其余4例病人术后恢复非常良好,无并发症。5例病人均获得随访,随访时间13-17个月。术后T管造影提示5例病人均无胆管狭窄,1例病人有结石残余,原因是当时胆道镜故障无法术中使用胆道镜探查取石,该病人不同意二期经T管窦道胆道镜取石而反复出血胆管炎,手术效果差。其余4例病人无结石残余,术后无症状,手术效果优。
结论：腹腔镜带蒂胆囊瓣胆道修复术治疗肝内胆管结石是安全可行的,可以解除肝门胆管的狭窄,保留胆道正常生理通道,无反流性胆管炎的风险,可以避免不必要的肝切除。伴有肝门胆管狭窄的肝内胆管结石并非腹腔镜手术的绝对禁忌症。
第三章腹腔镜在肝门部胆管肿瘤治疗中的应用(附3例报告)
目的：探讨腹腔镜肝门部胆管癌根治术治疗肝门部胆管肿瘤的可行性。
方法：2005年4月～2012年1月采用完全腹腔镜肝门部胆管癌根治术治疗3例肝门部胆管肿瘤的病人。根据肝门部胆管癌的Bismuth-Corlette临床分型,第一例为Ⅰ型肝门胆管癌,同时合并十二指肠乳头癌(双重癌)；第二例为Ⅰ型肝门部胆管癌；第三例肝门部胆管腺瘤。手术方式包括腹腔镜下肝外胆管切除,骨骼化清扫技术、左半肝切除、改良Roux-en-Y胆肠吻合术。
结果：所有病例均全部在腹腔镜下完成。手术时间420min～660min,平均520min。出血200ml～500ml,术中均未输血。术后恢复顺利,无死亡病例,术后1例短暂性胆漏,一例吻合口水肿所致呕吐,均经保守治疗治愈,术后10～23天出院,平均16.7天。随访所有病例至今均无瘤生存,最长一例已存活7年余。
结论：对于娴熟肝胆腹腔镜技术的外科医生,选择合适的病例,腹腔镜高位胆管肿瘤根治术是安全可行的,具有创伤小、痛苦轻的微创优势。
第四章腹腔镜胆道修复术在医源性胆管损伤中的应用研究
研究背景和目的：胆管损伤(bile duct injuries, BDI)是腹部外科严重的并发症,不仅会造成病人严重的损害,而且会极大地增加患者的医疗费用,容易引发医疗事故诉讼。医源性胆管损伤的发生率在腹腔镜时代较开腹时代增加了2-3倍,腹腔镜手术出现胆管损伤后通常需要中转开放手术修复或二期手术,给患者增加极大的痛苦。能否采用腹腔镜手术的方法进行胆管损伤的修复是一个值得探讨的问题。本研究的目的是探讨腹腔镜修复术治疗术中和术后早期发现的医源性胆管损伤的方法和可行性。
方法：总结分析2002年11月至2012年12月采用腹腔镜修复术治疗的12例术中或术后早期发现的医源性胆管损伤的资料。11例发生在腹腔镜胆囊切除术中(11/1485,0.74%),另1例发生于腹腔镜胃癌根治术中。男8例,女4例,平均年龄52.4岁(26-70岁)。其中6例为胆管轻度损伤,6例为高位胆管横断的重度胆管损伤。按刘允怡分类法,12例胆管损伤的损伤类型分别是：Ⅰ型2例,Ⅱ A型2例,ⅢA型2例,ⅣA型4例,ⅣB型2例。10例胆管损伤在术中发现,另2例在术后2天发现。针对不同的损伤类型采用不同的修复方法。2例肝总管部分轻度损伤(ⅡA型)的病人采用镜下缝合修补、T管引流来修复；1例右肝管孔状损伤的病人采用镜下单纯缝合修复；1例胆总管误扎的病人在镜下松解结扎线、胆总管探查、T管引流；1例胆囊床迷走小胆管的病人镜下缝扎封闭；1例胆囊颈残余胆漏的病人采用镜下切除残余胆囊、缝扎胆囊管的方法修复；另外6例高位胆管横断伤(肝总管或者左、右肝管横断伤)的病人采用镜下损伤的胆管对端吻合、硅胶支架管内引流的方法修复。
结果：12例BDI患者均完全腹腔镜下一期修复术,无中转开腹手术。术后患者恢复顺利,无腹腔感染、无伤口感染等并发症发生。胆管修复术后平均住院时间是9.25天(5-15天)。患者均获得随访,随访时间3月～10年不等。12例病人均无胆管狭窄。第8例患者发生过一次胆管炎,CT发现胆总管轻度扩张,行ERCP检查未发现胆总管结石,无胆管狭窄、肿瘤,考虑胆管轻度扩张为十二指肠乳头炎性狭窄引起,行EST后治愈。其余11例病人无胆管炎、胆管狭窄等长期并发症。
结论：轻度胆管损伤可以采用镜下单纯缝合修补或T管引流治疗,胆管横断损伤可以采用腹腔镜下胆管对端吻合术、支架引流管内引流管术的治疗。腹腔镜下胆管修复术用于治疗医源性胆管损伤是有效可行的。然而,手术的难度极大,技术要求高,必须由具有丰富的胆道外科手术和娴熟的腹腔镜技术的专家进行手术。
Chapter one
Laparoscopic Hepatectomies with cholangioscopy for Hepatolithiasis
Objective:To explore the feasibility and therapeutic effect of total laparoscopic hepatectomy (LH) for hepatolithiasis.
Methods:From November2003to November2012,75consecutive patients with hepatolithiasis were treated in our institute. Of the75patients with hepatolithiasis,35underwent LH (LH group) and40underwent open hepatectomies (OH group). Operative methods included left lateral lobectomy, left hemihepatecomy, choledochotomy, choledochoscopy and T tube drainage. Clinical data including operation time, intraoperative blood loss, rate of using pain relievers, ambulation time, oral intake time, postoperative complication rate, postoperative hospital stay time, stone clearance and recurrence rate were analyzed and compared between the two groups.
Results:The operative methods did not show significant difference between the two groups. The operation time of LH group was longer than that of OH group (205.0±40.9min VS155.0±26.6min, P<0.001) and the hospital stay time of LH group was shorter than that of OH group (12.3±2.6VS15.6±4.3, P<0.001).The intraoperative blood loss of LH group was more than that of OH group (330.0±259.7ml VS151.5±137.0ml, P=0.001).However, no difference was found in blood loss of last10cases between LH group and OH group (81.0±19.7VS78.0±22.0, P=0.752). The rate of using pain relievers in LH group was fewer than that of OH group(0%VS62.5%). Ambulation time (1.5±0.5VS3.6±0.7, P<0.001) and oral intake time (2.4±0.5vs4.0±0.7, P<0.001) of LH group were shorter than those in OH group. No difference was found in postoperative complication rate (2.9%VS16.0%), and stone clearance rate (intermediate rate91.4%VS90%and final rate97.1%VS100%) between the two groups. No perioperative death occurred in ether group.73patients (97.3%) were followed up for5-113months (mean41months), including35in LH group and38in OLH group. No difference was found in operative effect between the two groups(97.1%VS100%). Stone recurrence occurred in2patients of each group.
Conclusion:LH combined with choledochoscopy for hepatolithiasis is feasible and safe in selected patients with an equal therapeutic effect to that of traditional open hepatectomies. LH showed advanteages of minimally invasive surgery, such as small incision, less pain, fast recovery, less complications etc.
Chapter two Laparoscopic hilar cholangioplasty with pedicled gallbladder flap to treat hepatolithiasis complicated main hepatic duct stricture
Objective:The aim of the study was to explore the security and feasibility of laparoscopic hilar cholangioplasty with pedicled gallbladder flap to treat left hepatolithiasis complicated main hepatic duct stricture.
Methods:We performed laparoscopic hilar cholangioplasty with pedicled gallbladder flap for five patients who suffered from hepatolithiasis from November2011to February2012. They were all female. The mean age was47.4years (range25-60years). The operative procedures involved laparoscopic choledochotomy, choledochoscopy, patial cholecystectomy, hilar cholangioplasty with pedicled gallbladder flap, T tube drainage. Left lateral lobectomy was performed in three patients. We studied the clinical data of these five patients retrospectively.
Results:laparoscopic hilar cholangioplasty with pedicled gallbladder flap was successfully performed in5patients with no conversion to open surgery. There was no death. The mean operation time was274.6±25.4min (range250-310min). The mean intraopetive blood loss was130.0±97.5ml (range50-300ml).None of5patitends needed left hemihepatectomy.2patients had no hepatecomy. Other3patients underwent lateral lobectomy with left medial lobe reserved. Complications occurred in one patient. She suffered delayed abdominal hemorrhage because of spleen injury and pneumonia. She got recovered after a second operation and antibiotics treatment. Other4patients recovered very well without any complication. All patients received postoperative follow-up. The range of follow-up period was13-17months. Postoperative T-tube cholangiography showed no bile duct stricture in5patients. One of these five patients had retained stones because she couldn't received intraoperative choledoscopy while the choledochoscop broke down on that day. She refused a second choledochoscopy, and she had suffered cholangitis for several times because of the retained stons. The operation effect was bad for her. Other4patients had no symtoms after operation, and the operation effect was excellent for them.
Conclusion:Laparoscopic hilar cholangioplasty with pedicled gallbladder flap is a safe and feasible method for hepatolithiasis in selective patients.The operation could eliminate bile duct stricture and could keep normal bile duct anatomy so as to avoid the risk of reflux cholangitis. The operation could avoid unecessary hepatectomies. Hepatolithiasis complicated with main hepatic bile duct stricture was no longer contraindication to laparoscopic surgery.
Chapter Three The application of laparoscopy in the treatment for hilar cholangiocarcinoma:a report of3cases
Obejective:To evaluate the feasibility of laparoscopic radical resection for hilar bile duct tumor.
Methods:Total laparoscopic radical resections were carried out in3patients with hilar bile duct tumor. According to Bismuth-Corlette classification, case one fell into type I (he was also complicated with duodenal papillary carcinoma),case two fell into type II. Case three was cystadenoma. Operation procedures conclude extrahepatic duct resections, skeletal clearing technology, left hemihepatectomy, pancreaticoduodenectomy, modified Roux-en-Y cholangiojejunostomy.
Results:All operations were completed laparoscopically. Operative time was420min～660min (mean,520min). The blood loss was200ml-500ml (mean,333ml). No patient need blood transfusion. They recovered well without death. One patient had vomitting with suspected edema in the stoma of jejuno-jejunostomy. The third patient had transitory bile leak. They were cured with conservative treatments. They were discharged in10days～23days (mean,16.7days). All three patients survive with disease free until now. The longest survival period is more than7years, and the patient is still alive.
Conclusion:Laparoscopic radical resection can be a safe and feasible procedure for hilar bile duct tumor by laparoscopic hepatic experts in selected patients. Some advantages of minimally invasion surgery could be achieved.
Chapter Four The application of laparoscopic bile duct repair in the treatment of iatrogenic bile duct injuries
Background:Bile duct injuries (BDI)are a severe complication in abdominal surgery. BDI will cause serious damage to the patient and greatly increase medical expenses, and are likely to give rise to medical malpractice litigation. The incidence of iatrogenic BDI increased200%-300%in the laparoscopic era compared to that in the age of open surgery. Conversion to open surgery or two-stage operations were often needed when BDI occurred, which would cause more pain to patients. It is worth to explore whether laparoscopic repair are suitable for BDI. The aim of the study is to explore the methods and feasibility of laparoscopic repair and reconstruction for BDI found during operation and in early postoperative period.
Methods:From Feburary2002to December2012,12patients with BDI were treated with laparoscopic repairs during operation or in early postoperative period. The clinical data were collected and analyzed.11cases of BDI occurred in laparoscopic cholecystectomies (11/1485,0.74%), the other one case occurred in laparoscopic radical gastrectomy.8patients were male, and4patients were female. The mean age was52.4years (range26-70years).6BDI were mild injuries, and other6BDI were severe injuries (high-level bile duct transection). Wan-Yee Lau classification was used for these12BDI.2cases fell into type I,2into Ⅱ A,2into ⅢA,4into ⅣA,2into ⅣB.10BDI were found during operation, and other2BDI were found on the second day after opration. Methods of BDI were repaired according to type and severity of BDI.Laparoscopic suture and T-tube drainage were carried out in2mild partial common hepatic duct injuries (type ⅡA). Laparoscopic simple suture was performed in one patient with a hole-like injury in the right hepatic duct (type ⅣA). Laparoscopic common bile duct exploration, T-tube drainage, unfastening the thread were performed in one patient whose common bile duct was ligated incorrectly (type ⅢA). Laparoscopic closure by simple suturing was performed in one patient whose aberrant small bile duct at the gallbladder bed of live was injured (type Ⅰ). The retained neck of gallbladder was resected and the ocystic duct was sutured laparoscopically in one patient with retained neck of gallbladder and bile leak. Laparoscopic end-to-end bile duct anastomosis with silicone tube internal drainage were performed in6patients with high-level bile duct transection.
Results:Primary repaire of all12BDI were performed laparoscopically without conversion.They recovered very well without any complication. There was no death. The meaan hospital stay was9.25das (range5-15days).12patients received a follow-up from4months to10years.There was no bile duct stricture in the period of follow-up.Patient NO.8had cholangitis. Enhanced computed tomography scan showed mild dilated common bile duct. No bile duct stricture or tumor were found by ERCP. It was consider that the mild dilated common bile duct was caused by inflammatory stricture of Vater's papilla.The patient was cured with EST. There were no long-term complications such as cholangitis, bile duct stricture in other11patients.
Conclusion:Mild BDI could be fixed by laparoscopic simple suture or T tube drainage.Bile duct transection could be reconstructed by bile dut end-to-end anastomosis with silicone tube as stent for internal drainage. Laparoscopic repaire was feasible and effective for BDI. However, it is very difficult and technically demanding. Laparoscopic repair of BDI should be performed by biliary surgery specialist with excellent laparocopic skills.
目的：探讨应用腹腔镜肝切除术治疗肝内胆管结石的可行性和治疗效果。
方法从2003年11月至2012年11月,对75例肝内胆管结石病人进行了手术的治疗。其中35例病人进行了腹腔镜肝切除术(laparoscopic hepatectomies, LH组),40例病人采用开腹肝切除术进行治疗(open hepatectomies,OH组)。两组病人的手术方式包括左肝外叶切除术、左半肝切除术、胆总管切开探查、胆道镜探查取石、T管引流、胆囊切除术。分析和对比两组病人的临床资料包括手术时间、术中出血量、术后止痛药使用情况、下床活动时间、恢复饮食时间、术后并发症、术后住院时间、结石清除率和复发率等因素。
结果：两组病人手术方式对比无显著差别。腹腔镜组的手术时间长于开腹组(205.0±40.9min VS155.0±26.6min, P<0.001)。腹腔镜组的术后住院时间比开腹组的短(12.3±2.6VS15.6±4.3,P<0.001)。腹腔镜组的术中出血量稍多于开腹手术组(330.0±259.7ml VS151.5±137.0ml,P=0.001),然而腹腔镜组后10例病人的出血量与开腹组的相当(81.0±19.7ml VS78.0±22.Oml,P=0.752)。腹腔镜组术后止痛药使用率低于开腹组(0%VS62.5%,P<0.001)。腹腔镜组比开腹组更早地恢复下床活动(1.5±0.5天VS3.6±0.7天,P<0.001)和进食时间(2.4±0.5天vs4.0±0.7天,P<0.001)。术后并发症发生率(2.9%VS16.0%)、结石清除率(即时清除率91.4%VS90%和最终清除率97.1%VS100%)在两组间均无明显差别,P>0.05。两组病人都没有围手术期死亡病人。73例(97.3%)病人获得随访,包括开腹组38例和腹腔镜组35,随访时间为5～113个月,平均41个月。腹腔镜组合开腹组的手术优良率无显著差别(97.1%VS100%,P=0.479)。每组分别有2例病人结石复发。
结论：选择合适的病例,腹腔镜肝切除术联合胆道镜治疗肝内胆管结石是安全可行的,可以达到与开腹手术同样良好的效果。腹腔镜肝切治疗肝内胆管结石具有伤口小、痛苦轻、恢复快、并发症少等微创手术的优势。
第二章腹腔镜带蒂胆囊瓣胆道修复术治疗合并主肝管狭窄的肝内胆管结石的应用研究
目的：探讨腹腔镜带蒂胆囊瓣胆道修复术治疗合并主管狭窄的左肝内胆管结石的安全性和可行性。
方法：2011年11月～2012年2月,对5例合并左主肝管狭窄的肝内胆管结石的患者施行腹腔镜带蒂胆囊瓣胆道修复术,5例均为女性,年龄25～60岁,平均47.4岁。手术方式为腹腔镜胆总管切开,胆道镜探查取石,胆囊部分切除,带蒂胆囊瓣胆道修复,T管引流术,其中有3例患者同时切除了肝左外叶。
结果：5例均成功完成腹腔镜带蒂胆囊瓣胆道修复术,无中转开腹,无死亡病例,平均手术时间274.6±25.4min(250-310min),平均术中出血量130.0±97.5m1(50-300m1)。5例病人均不需要进行左半肝切除术,其中2例病人不需要肝切除,其余3例病人只切除了肝左外叶,保留了肝左内叶的肝组织。1例病人出现并发症,该病人因脾损伤术后发生延迟性腹腔出血和肺炎,经过二次手术和抗生素治疗后治愈。其余4例病人术后恢复非常良好,无并发症。5例病人均获得随访,随访时间13-17个月。术后T管造影提示5例病人均无胆管狭窄,1例病人有结石残余,原因是当时胆道镜故障无法术中使用胆道镜探查取石,该病人不同意二期经T管窦道胆道镜取石而反复出血胆管炎,手术效果差。其余4例病人无结石残余,术后无症状,手术效果优。
结论：腹腔镜带蒂胆囊瓣胆道修复术治疗肝内胆管结石是安全可行的,可以解除肝门胆管的狭窄,保留胆道正常生理通道,无反流性胆管炎的风险,可以避免不必要的肝切除。伴有肝门胆管狭窄的肝内胆管结石并非腹腔镜手术的绝对禁忌症。
第三章腹腔镜在肝门部胆管肿瘤治疗中的应用(附3例报告)
目的：探讨腹腔镜肝门部胆管癌根治术治疗肝门部胆管肿瘤的可行性。
方法：2005年4月～2012年1月采用完全腹腔镜肝门部胆管癌根治术治疗3例肝门部胆管肿瘤的病人。根据肝门部胆管癌的Bismuth-Corlette临床分型,第一例为Ⅰ型肝门胆管癌,同时合并十二指肠乳头癌(双重癌)；第二例为Ⅰ型肝门部胆管癌；第三例肝门部胆管腺瘤。手术方式包括腹腔镜下肝外胆管切除,骨骼化清扫技术、左半肝切除、改良Roux-en-Y胆肠吻合术。
结果：所有病例均全部在腹腔镜下完成。手术时间420min～660min,平均520min。出血200ml～500ml,术中均未输血。术后恢复顺利,无死亡病例,术后1例短暂性胆漏,一例吻合口水肿所致呕吐,均经保守治疗治愈,术后10～23天出院,平均16.7天。随访所有病例至今均无瘤生存,最长一例已存活7年余。
结论：对于娴熟肝胆腹腔镜技术的外科医生,选择合适的病例,腹腔镜高位胆管肿瘤根治术是安全可行的,具有创伤小、痛苦轻的微创优势。
第四章腹腔镜胆道修复术在医源性胆管损伤中的应用研究
研究背景和目的：胆管损伤(bile duct injuries, BDI)是腹部外科严重的并发症,不仅会造成病人严重的损害,而且会极大地增加患者的医疗费用,容易引发医疗事故诉讼。医源性胆管损伤的发生率在腹腔镜时代较开腹时代增加了2-3倍,腹腔镜手术出现胆管损伤后通常需要中转开放手术修复或二期手术,给患者增加极大的痛苦。能否采用腹腔镜手术的方法进行胆管损伤的修复是一个值得探讨的问题。本研究的目的是探讨腹腔镜修复术治疗术中和术后早期发现的医源性胆管损伤的方法和可行性。
方法：总结分析2002年11月至2012年12月采用腹腔镜修复术治疗的12例术中或术后早期发现的医源性胆管损伤的资料。11例发生在腹腔镜胆囊切除术中(11/1485,0.74%),另1例发生于腹腔镜胃癌根治术中。男8例,女4例,平均年龄52.4岁(26-70岁)。其中6例为胆管轻度损伤,6例为高位胆管横断的重度胆管损伤。按刘允怡分类法,12例胆管损伤的损伤类型分别是：Ⅰ型2例,Ⅱ A型2例,ⅢA型2例,ⅣA型4例,ⅣB型2例。10例胆管损伤在术中发现,另2例在术后2天发现。针对不同的损伤类型采用不同的修复方法。2例肝总管部分轻度损伤(ⅡA型)的病人采用镜下缝合修补、T管引流来修复；1例右肝管孔状损伤的病人采用镜下单纯缝合修复；1例胆总管误扎的病人在镜下松解结扎线、胆总管探查、T管引流；1例胆囊床迷走小胆管的病人镜下缝扎封闭；1例胆囊颈残余胆漏的病人采用镜下切除残余胆囊、缝扎胆囊管的方法修复；另外6例高位胆管横断伤(肝总管或者左、右肝管横断伤)的病人采用镜下损伤的胆管对端吻合、硅胶支架管内引流的方法修复。
结果：12例BDI患者均完全腹腔镜下一期修复术,无中转开腹手术。术后患者恢复顺利,无腹腔感染、无伤口感染等并发症发生。胆管修复术后平均住院时间是9.25天(5-15天)。患者均获得随访,随访时间3月～10年不等。12例病人均无胆管狭窄。第8例患者发生过一次胆管炎,CT发现胆总管轻度扩张,行ERCP检查未发现胆总管结石,无胆管狭窄、肿瘤,考虑胆管轻度扩张为十二指肠乳头炎性狭窄引起,行EST后治愈。其余11例病人无胆管炎、胆管狭窄等长期并发症。
结论：轻度胆管损伤可以采用镜下单纯缝合修补或T管引流治疗,胆管横断损伤可以采用腹腔镜下胆管对端吻合术、支架引流管内引流管术的治疗。腹腔镜下胆管修复术用于治疗医源性胆管损伤是有效可行的。然而,手术的难度极大,技术要求高,必须由具有丰富的胆道外科手术和娴熟的腹腔镜技术的专家进行手术。
Chapter one
Laparoscopic Hepatectomies with cholangioscopy for Hepatolithiasis
Objective:To explore the feasibility and therapeutic effect of total laparoscopic hepatectomy (LH) for hepatolithiasis.
Methods:From November2003to November2012,75consecutive patients with hepatolithiasis were treated in our institute. Of the75patients with hepatolithiasis,35underwent LH (LH group) and40underwent open hepatectomies (OH group). Operative methods included left lateral lobectomy, left hemihepatecomy, choledochotomy, choledochoscopy and T tube drainage. Clinical data including operation time, intraoperative blood loss, rate of using pain relievers, ambulation time, oral intake time, postoperative complication rate, postoperative hospital stay time, stone clearance and recurrence rate were analyzed and compared between the two groups.
Results:The operative methods did not show significant difference between the two groups. The operation time of LH group was longer than that of OH group (205.0±40.9min VS155.0±26.6min, P<0.001) and the hospital stay time of LH group was shorter than that of OH group (12.3±2.6VS15.6±4.3, P<0.001).The intraoperative blood loss of LH group was more than that of OH group (330.0±259.7ml VS151.5±137.0ml, P=0.001).However, no difference was found in blood loss of last10cases between LH group and OH group (81.0±19.7VS78.0±22.0, P=0.752). The rate of using pain relievers in LH group was fewer than that of OH group(0%VS62.5%). Ambulation time (1.5±0.5VS3.6±0.7, P<0.001) and oral intake time (2.4±0.5vs4.0±0.7, P<0.001) of LH group were shorter than those in OH group. No difference was found in postoperative complication rate (2.9%VS16.0%), and stone clearance rate (intermediate rate91.4%VS90%and final rate97.1%VS100%) between the two groups. No perioperative death occurred in ether group.73patients (97.3%) were followed up for5-113months (mean41months), including35in LH group and38in OLH group. No difference was found in operative effect between the two groups(97.1%VS100%). Stone recurrence occurred in2patients of each group.
Conclusion:LH combined with choledochoscopy for hepatolithiasis is feasible and safe in selected patients with an equal therapeutic effect to that of traditional open hepatectomies. LH showed advanteages of minimally invasive surgery, such as small incision, less pain, fast recovery, less complications etc.
Chapter two Laparoscopic hilar cholangioplasty with pedicled gallbladder flap to treat hepatolithiasis complicated main hepatic duct stricture
Objective:The aim of the study was to explore the security and feasibility of laparoscopic hilar cholangioplasty with pedicled gallbladder flap to treat left hepatolithiasis complicated main hepatic duct stricture.
Methods:We performed laparoscopic hilar cholangioplasty with pedicled gallbladder flap for five patients who suffered from hepatolithiasis from November2011to February2012. They were all female. The mean age was47.4years (range25-60years). The operative procedures involved laparoscopic choledochotomy, choledochoscopy, patial cholecystectomy, hilar cholangioplasty with pedicled gallbladder flap, T tube drainage. Left lateral lobectomy was performed in three patients. We studied the clinical data of these five patients retrospectively.
Results:laparoscopic hilar cholangioplasty with pedicled gallbladder flap was successfully performed in5patients with no conversion to open surgery. There was no death. The mean operation time was274.6±25.4min (range250-310min). The mean intraopetive blood loss was130.0±97.5ml (range50-300ml).None of5patitends needed left hemihepatectomy.2patients had no hepatecomy. Other3patients underwent lateral lobectomy with left medial lobe reserved. Complications occurred in one patient. She suffered delayed abdominal hemorrhage because of spleen injury and pneumonia. She got recovered after a second operation and antibiotics treatment. Other4patients recovered very well without any complication. All patients received postoperative follow-up. The range of follow-up period was13-17months. Postoperative T-tube cholangiography showed no bile duct stricture in5patients. One of these five patients had retained stones because she couldn't received intraoperative choledoscopy while the choledochoscop broke down on that day. She refused a second choledochoscopy, and she had suffered cholangitis for several times because of the retained stons. The operation effect was bad for her. Other4patients had no symtoms after operation, and the operation effect was excellent for them.
Conclusion:Laparoscopic hilar cholangioplasty with pedicled gallbladder flap is a safe and feasible method for hepatolithiasis in selective patients.The operation could eliminate bile duct stricture and could keep normal bile duct anatomy so as to avoid the risk of reflux cholangitis. The operation could avoid unecessary hepatectomies. Hepatolithiasis complicated with main hepatic bile duct stricture was no longer contraindication to laparoscopic surgery.
Chapter Three The application of laparoscopy in the treatment for hilar cholangiocarcinoma:a report of3cases
Obejective:To evaluate the feasibility of laparoscopic radical resection for hilar bile duct tumor.
Methods:Total laparoscopic radical resections were carried out in3patients with hilar bile duct tumor. According to Bismuth-Corlette classification, case one fell into type I (he was also complicated with duodenal papillary carcinoma),case two fell into type II. Case three was cystadenoma. Operation procedures conclude extrahepatic duct resections, skeletal clearing technology, left hemihepatectomy, pancreaticoduodenectomy, modified Roux-en-Y cholangiojejunostomy.
Results:All operations were completed laparoscopically. Operative time was420min～660min (mean,520min). The blood loss was200ml-500ml (mean,333ml). No patient need blood transfusion. They recovered well without death. One patient had vomitting with suspected edema in the stoma of jejuno-jejunostomy. The third patient had transitory bile leak. They were cured with conservative treatments. They were discharged in10days～23days (mean,16.7days). All three patients survive with disease free until now. The longest survival period is more than7years, and the patient is still alive.
Conclusion:Laparoscopic radical resection can be a safe and feasible procedure for hilar bile duct tumor by laparoscopic hepatic experts in selected patients. Some advantages of minimally invasion surgery could be achieved.
Chapter Four The application of laparoscopic bile duct repair in the treatment of iatrogenic bile duct injuries
Background:Bile duct injuries (BDI)are a severe complication in abdominal surgery. BDI will cause serious damage to the patient and greatly increase medical expenses, and are likely to give rise to medical malpractice litigation. The incidence of iatrogenic BDI increased200%-300%in the laparoscopic era compared to that in the age of open surgery. Conversion to open surgery or two-stage operations were often needed when BDI occurred, which would cause more pain to patients. It is worth to explore whether laparoscopic repair are suitable for BDI. The aim of the study is to explore the methods and feasibility of laparoscopic repair and reconstruction for BDI found during operation and in early postoperative period.
Methods:From Feburary2002to December2012,12patients with BDI were treated with laparoscopic repairs during operation or in early postoperative period. The clinical data were collected and analyzed.11cases of BDI occurred in laparoscopic cholecystectomies (11/1485,0.74%), the other one case occurred in laparoscopic radical gastrectomy.8patients were male, and4patients were female. The mean age was52.4years (range26-70years).6BDI were mild injuries, and other6BDI were severe injuries (high-level bile duct transection). Wan-Yee Lau classification was used for these12BDI.2cases fell into type I,2into Ⅱ A,2into ⅢA,4into ⅣA,2into ⅣB.10BDI were found during operation, and other2BDI were found on the second day after opration. Methods of BDI were repaired according to type and severity of BDI.Laparoscopic suture and T-tube drainage were carried out in2mild partial common hepatic duct injuries (type ⅡA). Laparoscopic simple suture was performed in one patient with a hole-like injury in the right hepatic duct (type ⅣA). Laparoscopic common bile duct exploration, T-tube drainage, unfastening the thread were performed in one patient whose common bile duct was ligated incorrectly (type ⅢA). Laparoscopic closure by simple suturing was performed in one patient whose aberrant small bile duct at the gallbladder bed of live was injured (type Ⅰ). The retained neck of gallbladder was resected and the ocystic duct was sutured laparoscopically in one patient with retained neck of gallbladder and bile leak. Laparoscopic end-to-end bile duct anastomosis with silicone tube internal drainage were performed in6patients with high-level bile duct transection.
Results:Primary repaire of all12BDI were performed laparoscopically without conversion.They recovered very well without any complication. There was no death. The meaan hospital stay was9.25das (range5-15days).12patients received a follow-up from4months to10years.There was no bile duct stricture in the period of follow-up.Patient NO.8had cholangitis. Enhanced computed tomography scan showed mild dilated common bile duct. No bile duct stricture or tumor were found by ERCP. It was consider that the mild dilated common bile duct was caused by inflammatory stricture of Vater's papilla.The patient was cured with EST. There were no long-term complications such as cholangitis, bile duct stricture in other11patients.
Conclusion:Mild BDI could be fixed by laparoscopic simple suture or T tube drainage.Bile duct transection could be reconstructed by bile dut end-to-end anastomosis with silicone tube as stent for internal drainage. Laparoscopic repaire was feasible and effective for BDI. However, it is very difficult and technically demanding. Laparoscopic repair of BDI should be performed by biliary surgery specialist with excellent laparocopic skills.
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